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.q��N - �ll�Y MA YS t APPLICATION FOR PERMIT N40"�f SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE i ON AVE„ STOCKTON, CA Telephone (200) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED {Complete in TriplicatO Application Is hereby made to the San Joaquin Local Haallh District for a permit to construct and/or install the work herein described. This application is math u1 c141:11111,Inco with n Jrldquin Crn,nty`Ortimancu No. 543 for sewargn or No, IB62 for welllpump and ilia Rules anti Hooulatlons of ilia San Joarlour I.ucal tivaltn thstrict. PA�Crk S J Job Address 7 QO r/p� E City MAC Lot Site 150X/ST3 PM Owner's Name tO2?lk Address =Fg_00 It Ff� SL//TE 7� Phone 6-3/_LJ Address ?_L'). Conllactor /S e4_License No. yJ TYPE OF WELI-IPUMP: NEW WELL i_I WELL REPLACEMENT i i DESTRUCTION n d S l IL— PUMP INSTALLATION Li SYSTEM REPAIR !.l OTHER f� Sol rf 5 r V DISTANCE TO NEAREST: SEPTIC TANK —C11 f SEWER LINES ? DISPOSAL FLD.1!* PROP. LINE FOUNDATION _.-2� i AGRICULTURE WELL Q-51—4 OTHER WELL Mtge PITS/SUMPS �rr•rG INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS T'Q IC'/N S i i Industrial- Yf IJ-Open Bottom CI Manteca _ Ota. of Well Excavation —1QDia, of Well Casing — I 1 Domestic/Private I i Gravel Pack l4racy Type of Casing Specifications Publre f I Other i i Delta Depth of Grout Seal .__ Type of Grnru�'cnit+ ( <_t-iY1 ✓t iro.ganun r'a Approx. Depth Eastern Surlacu Sual Installad by ---- R4pau Work Dunc rypu of Pump �.-- IA P. _-- -- Stara Work Unna -- ------___-- � 4 Vull Desimcilon Ll Well Diameter Sealing Material Itop fi0') Depth Filler Material lBelow 50'1 -- TYPE OF SEPTIC WORK. NEW INSTAI LATION l I REPAIR/ADDITION I I DESTRUCTION I I (No septic System permitted if public SCWur is available within 200 feet.) Installation will serve: Rusulencu _ Cummurcial -- Other Number o1 livrnu units: Number of bedrooms s r� Cliaracrer of still to a depth of 3 feet: -Water Oble depth —_--- .- SEPTIC TANK 1.1 Type/Mtg —_ Cipacity _— No. artments r PKG. TREATMENT PI-T. l I Me 1. -- ----------.- f 1} Distance, to nr.art:St: Wall _4_ _ _-- Foundduan -_- - Properly Iki0�'�'ig v?`' I -------- ---- t EAi:HINI; L11`tE I 1 No. & Length of linos Total I�� "tJ 77 1-11 ]Eli BED - "I Dlstanru to nearest: - Weil r Fuundabon -EN1l//'r e - 1 tilErSl),,4'tlt r�1� R SELI'A6E PITS I I Dop�i -_-- .--- —Situ —.----- __-- Ntimbur 'y�ALT�1 V vvEs--- SUMPS I I Distancu to nearest: WellFoundation —_—____ Property tine ��slQv ^� DISPOSAL_ PONDS I I f I hureby cattily that I have prepared this application and that ttiu work will he done in accur(lanco with San Joaquin county oidmancu5, sidle laws, .incl rules and leuu)duuos of Iho San Joaquin Local Health D.smct. Home owner of Iiconsad a{geni's signature cartilius the following: "I certify that in tho podonnance of the work for which this purmit is issued. I shatl not employ ally parson in such manner as Io hecoma Sulljoct to workman's cornpausalton laws of California." Contractor's hiring or sob ronrractin+g Si{IndLtuu curofres Ilia lullowrnu: "I certify that to the lwrlormanco of the work for which(1115 perrrut is ISsuad, I shall employ persons subluct to workman's cornpurisa tion laws of California.- Tliu applicant must call fol all ruquirod inspoctions.rnplota drawmij an rovursu side. // _—( �('�iT Data: %/G Signed X r 'C.�7}1!t Title: �t i T G" �L N� R DEPARTMENT USE ONLY �j f� Application Accapied by _ _—_ Date y Aroa v -._------ Pit or Grout Inspoction Uy/} yD,,a�ta � �� Final Inysprictionl by /� .`� 1" Date Additional Commonts: 9 VMI,4-5 1,5✓�� t/uSt��i..k &VASLk ' 1 19 u�w r-T/ , ( cch"' Y neeisLl-_ I l Sik 466 67t11 l-) Lorli 369 3621 ❑ Mantoca 823-7104 f-1 Tracy ais 6385 Applicant - Return all copies to: Environmental Hetrldl Purmit/Services 1601 E. Hazelton Ave.. P.O. Box 2009, Sik., CA 95201 1. FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. ii INFO Eli1324 MEV r. 5-51q oo 'qy